Anxiety plays a major role in the development of the problems associated with erectile dysfunction (ED). Psychological and behavioural responses to ED can lead to a vicious cycle of increased uneasiness, distance and conflicts. This in turn leads to a lower frequency of sexual encounters, less time spent together and lack of communication between partners in a relationship. In this review, methods to decrease sexual anxiety are discussed. Primary care psychosexual counselling including a detailed explanation of ED, reassurance to the patient and proposal of a solution for ED are outlined. A multidisciplinary approach to ED therapy is recommended using psychosexual counselling in conjuction with pharmacotherapy.
Key issues in anxiety and erectile dysfunction
Anxiety is a well-known aetiological factor in the development of erectile dysfunction (ED).1 There are three key issues a physician must consider when treating anxiety and ED. Firstly, ED often results from a combination of different causes, which comprise of organic and psychogenic factors that occur at the same period of a man's life.2,3,4 Secondly, anxiety may be confused with depression or sexual desire disorder; however, this can be prevented by discussing the key issues with each patient. Finally, anxiety is a normal response to personal and health issues; and not a pathological response.5
It is essential for physicians treating ED to consider a global approach to ED therapy that deals with anxiety. Central initiators such as apomorphine SL (Ixense™) (apo SL) are of use in helping to break the failure cycle that becomes a part of ED.6 The resulting physiological erection helps to normalise the sexual situation of the couple thus alleviating the anxiety.
Causes of anxiety
There are multiple life stressors that can lead to anxiety and in turn induce secondary ED. These stressful events can be job related (stress, travelling, responsibility), couple related (divorce, conflicts, widower's syndrome), age related (generally feeling old, fear of death), health related (illnesses, surgery) or even be side effects from other drug therapies (Table 1). These situations are a part of everyday life that in some instances can lead to anxiety. If several of these events occur simultaneously the consequences can be multiplied.
In addition to life stressors resulting in anxiety, erectile problems themselves can lead to specific anxiety. Performance anxiety, resulting from the patient's concerns over his erectile response and durability of his erection, is always present even if at different levels. Narcissistic perturbation is yet another psychological consequence of ED that further increases anxiety. The patient's self-esteem may sink further causing concern for both himself and his partner. This may result in behavioural modifications in the patient, such as avoiding intimacy and temper outbursts. These factors lead to increasing anxiety and increasing ED resulting in a vicious cycle of failure and escalating anxiety (Figure 1).7
The anxiety/erectile dysfunction cycle
The vicious cycle of failure and escalating anxiety resulting from ED affects not only the patient but also the patient's partner (Figure 1).7 Typical concerns of the female partner are that she is no longer attractive to her partner; that she is getting too old for him to desire her; that her partner no longer loves her. In addition, she may also worry about her partner's fidelity. Frustration, not just sexual frustration, but a frustration at the lack of tenderness in the relationship can develop. As with the patient, the resulting partner's anxiety may lead to behavioural modifications, for example she may become clumsy and unsure how to behave with her partner, particularly in bed.
The vicious cycle of anxiety and erectile dysfunction encompasses the entire relationship between the patient and the partner. It becomes increasingly difficult to break out of as both sides modify their behaviour in response to the anxiety that they are experiencing. As the anxiety issues raised by either partner in the relationship are different, this further deepens the communication problems and a lack of understanding develops on both sides.
Multidisciplinary approaches to ED: combining psychosexualcounselling and pharmacotherapy
The need to break out of the vicious cycle created within a relationship by ED ensures that any effective long-term therapy will need to provide a global approach that treats anxiety and relationship issues in addition to the ED.
Central initiators of erection such as apo SL can help to break the failure cycle by removing the anxious inhibition related to anticipation of failure. If allowed, it can reinitiate a positive sexual experience for the couple, which, while very important, does not provide a complete solution to the problem. Most patients have often suffered from ED mid- or long-term; therefore, patients need to rebalance physically and mentally. Anxiety issues and communication problems within the relationship will not be solved simply because the male is able to have an erection. Deeper seated issues have to be addressed if a true therapy is to be applied. This must be stressed to the patient, as ED patients have a tendency to focus on the quality of the erection rather than on the messages being conveyed by his body. This results in a loss of sensitivity and reduction in the emotional aspects of sex and frequently the patient needs to be made aware of this.
Simple methods of primary care counselling
Sexual anxiety counselling can be performed in a primary care setting using simple guidelines. The key objectives are to explain ED fully to the patients in order to reduce worry related to lack of knowledge; reassure the patient that their problems are not unique and that they can be overcome and finally to propose positive action that the patient and partner can take to help overcome the problems (Figure 2).
The physician/urologist should fully explain the mechanisms involved in erections and erection failure. This explanation should be fairly detailed, discussing the role of vasculature, neurotransmitters and central mechanisms. The use of metaphors and simple language (according to individual patients) will ensure that the patient completely understands the mechanisms behind ED. An explanation of the mechanism of action of the drug to be prescribed is also essential for successful therapy.
Once the patient has some basic knowledge of the physical side of his problem, emotional issues need to be addressed. It is important for the physician to discuss the links between life events, health issues and ED. These links may appear obvious to a physician or counsellor but not necessarily to a patient. The difference between desire and erection, erectile dysfunction and impotence are also important differentiations that the patient needs to understand. The vicious cycle of erectile failure should also be explained by the physician, including the impact that ED will have on the patient's partner. Most patients will recognise the worsening cycle of ED and anxiety as soon as it is pointed out and will appreciate that it is understood and is a common situation.
Reassuring the patient
The physician should reassure the patient that they are not alone and that there are solutions to the problem of ED in order to overcome some of the initial anxiety that the patient will be experiencing. This reassurance will require a number of issues to be addressed by the physician, including advising the patient that ED is a common problem in the average male population and that he is not unusual or less manly because of it. The patient also needs reassurance about any pharmacotherapy that the physician is prescribing and the impact that it will have on his ED. For a central initiator such as apo SL, the patient can be assured that it is effective and has minimal side effects. In addition, the physician should discuss the short delay of action with the patient and how this will help him to recover physiological timing for sexual encounters. By explaining the combined role of the ED therapy with psychosexual counselling, the physician can help the patient overcome the vicious cycle and turn it into a virtuous one.
There are a number of action points that can be proposed to the patient to help break the vicious cycle. A key point is that the patient needs to be told not to focus on his erection, and to try not to control his erection. The mechanisms of erectile function will have been explained to the patient and therefore the physician should remind him that erections are a reflex response and emphasise the importance of relaxation. Erections are not under the conscious control of the patient. In order to achieve this relaxation, the patient should be told to seek situations creating desire and arousal and to focus on positive images rather than anticipate failure. This may be assisted using pharmacotherapy as success will breed success. The patient also needs to be advised to reactivate his imagination. Patients generally report that this has become dulled because of long-term ED. Focusing on sensations is also important, the focus on erection quality can mean that patients neglect other aspects of the sexual experience and it is important that they attempt to regain the full range of sensations involved.
Action points that the patient should apply to the relationship are vital and can be discussed by the physician as two main issues. Firstly, the patient needs to improve communication within the relationship and specific ways to achieve this can be given. The patient should be advised to discuss the feelings that both partners have about the situation rather than hiding the problem. Importantly, the patient should reassure his partner that his lack of erectile function has nothing to do with negative feelings towards her. The patient can also be advised to discuss his medication with his partner and explain how it will help the couple break out of the failure cycle. The second relationship action point is that the patient needs to revisit the sexual relationship, spending more quality time with his partner, being more affectionate and give more importance to affection such as kissing, cuddling and stroking. Sexuality is not just about intercourse. The patient should also be made aware that his frustration may result in irritation. Psychosexual counselling should be provided, offering solutions on how best to manage anger.
With its multidimensional approach to pharmacotherapy, apo SL provides good efficacy and the potential to recover a satisfactory intimacy and sexual life. Used in conjunction with psychosexual counselling this potential is greatly expanded. An experienced physician/urologist can apply simple counselling techniques in conjunction with the prescription of pharmacotherapy, such as apo SL.8 However, a truly multidisciplinary approach can also be provided if a urologist and therapist work together.9 Team work is essential if this approach is to work successfully, not just between the urologist and the therapist, but also with the couple who should have the multidisciplinary approach to therapy fully explained.
About this article
Current Sexual Health Reports (2006)